2581.4 PREPARATION AND USE OF SCIF 3067 (STATE) FORM
(Revised 12/99)
Before SCIF can pay medical expenses or verify temporary disability, it must have a completed Employer's Report of Occupational Injury or Illness, SCIF 3067 (STATE). The California Occupational Safety and Health Act requires you to report within five days every job-related injury or occupational disease. Submit SCIF 3067 (STATE), in duplicate. A delay in employee benefits could result from late reporting. Automatic penalties will be assessed for late reporting as well. It is not necessary to submit SCIF 3067 (STATE) for occurrences that require only self-administered first aid.
However, SCIF 3067, (STATE) must be submitted when the employee requires more medical care than first aid, or the employee's disability lasts beyond the day of injury. The original becomes the basis for the SCIF's claim file. The duplicate is forwarded by SCIF to the Division of Labor Statistics and Research, Department of Industrial Relations, as required by law. SCIF 3067, (STATE) may be obtained from your departmental safety officer or by calling the nearest SCIF office listed in the State of California Telephone Directory, under the Department of Industrial Relations. Your personnel office may also have blank SCIF 3067 (STATE).
Agencies shall authorize designated individuals to sign SCIF 3067 (STATE). It is not necessary to inform SCIF of those who are so authorized. The person authorized to sign the form is responsible for the accuracy of all information. This form is state management's report of the incident to SCIF and is considered confidential. If later it is discovered that any information provided was inaccurate, this must be reported to the SCIF.
Someone other than a supervisor to the injured person should fill out the SCIF 3067 (STATE). The form shall not be completed by the injured employee, and UNDER NO CIRCUMSTANCES IS THE INJURED EMPLOYEE TO SIGN THE SCIF 3067 (STATE). It is important that questionable facts about the alleged circumstances of injury or death be reported to the SCIF office so that they may make whatever special investigation is necessary. Additional information on a claim should be communicated to the SCIF office by separate memorandum, or by use of the Supplemental Information Regarding Work Disability form, SCIF 3068.
It is important that the correct agency payroll code, as used in the uniform state payroll system or the Workers' Compensation Insurance policy number be shown in part 1A of the form. The policy number instead of the agency payroll code is used whenever the injured employee is paid from funds covered by a Workers' Compensation Insurance policy.
